Agency Applications


United Way of the Shippensburg Area Funding Contract 


 We, the Board of Directors of the United Way of the Shippensburg Area to confirm our commitment for funding of participating agencies, are requesting the following contract be signed by agencies that accept United Way of the Shippensburg Area funding.  This commitment will be mutually beneficial in publicizing funding needs, doing what matters for our community.

 Each agency must provide a brief overview, or outline of the services provided to Shippensburg Area residents.  Agencies will also provide a true and correct copy of the application, annual audit or financial review, along with accompanying financial statements.  Since the United Way is raising money on the agency’s behalf, as a courtesy other fundraising activities are to be avoided from September 1st to September 15th each calendar year.  The member agency must remain a non-profit organization.  Agencies are to provide services without discrimination, and have a policy that reflects that intention.  Each agency must have a public spokesperson available to media and/or service organizations to highlight their activities in the Shippensburg Area.  Agencies should also include in communications that they are an agency of the United Way of the Shippensburg Area. 

 In the event that a member agency violates the terms of this agreement, the United Way reserves the right to withhold any funds not previously distributed and to drop the agency from the list of member agencies of the United Way.

 Agency Name___________________________________________________________________

 Agency Signature________________________________________________________________

 Contact Person____________________________________ Title__________________________

 E-mail Contact:__________________________________________________________________

 Phone#___________________________________ Fax #_________________________________

Treasurers Name_________________________________________________________________

Treasurers Phone#________________________________________________________________

 We believe this agreement will strengthen The United Way of the Shippensburg Area and its participating agencies’ commitment to the Fund Drive and together we can further the Goal of this year’s Fund Drive.



United Way of the Shippensburg Area Agency Request for Funds

Agency Request for Funds


Agency Name_______________________________________________________________________________________



Phone Number______________________________________     

Fax Number____________________________________

Contact Person & E-Mail _____________________________________________________________________________


Please write a short 1-sentence description of your agency for inclusion in the United Way of the Shippensburg Area brochure:



Amount Requested for upcoming campaign                                              $_____________________________

Found on brochure, Amount Received in Prior Year Campaign                $_____________________________

 Reason for change (if any) in the requested amount:

 How will the funds be utilized to serve the Shippensburg Area?


What Percentage of Your Yearly Operating Budget is Expended in the Shippensburg Area?           ____________________________%


 How Many People in the Shippensburg Area Actually Received Direct Services or Participated in Your Programs During the prior year Campaign?


 How Many People in the Shippensburg Area Does Your Organization Anticipate Will Receive Services or Participate in Your Programs During the prior year Campaign?                   ______________________________




Budget Information (Please be accurate)



What is your fiscal year of information that you are providing:______________________________

Attach a copy of last years actual budget, and a copy of the projected budget for the upcoming year.


What Percentage of Your Yearly Operating Budget is expended for Administrative Costs? _________________________%

Derived from the IRS Form 990: Add (management and general) and (fundraising), divide the result by (total revenue).  The result is the Percentage of administrative costs for your organization.  It may need rounded to the tenth of a percent.


Total Yearly Operating Budget                                                               $______________________________________

Total Yearly Income                                                                              $______________________________________


Please Provide the Current Amount of Money in Your Reserve and Operating Accounts:

Checking Accounts       $____________________          

Traditional Saving Accounts       $__________________

Certificates of Deposit  $____________________          

Money Market Accounts             $__________________

Stocks/Mutual Funds     $____________________          

Bonds/Bond Funds                   $__________________

Other                            $____________________

Total     $_____________________________________


Please Provide the Current Monetary Value of Your Organization’s:

Equipment                    $_____________________         

Buildings                                 $________________________

Vehicles                        $_____________________         

Real Estate                              $________________________

Other                            $_____________________

Total     $_____________________________________



Please Provide the Current Amount, By Source, of Your Yearly Income:

Fees for Service                        $_________________    

Registration Fees                                     $__________________

Fund Raising Programs             $_________________    

Private Contributions                               $__________________

Membership Fees                      $_________________    

Federal Aid                                             $__________________

State Aid                                  $_________________    

County/Local Aid                                    $__________________

United Way Funds                     $_________________    

Dividends/Interest                                   $__________________

Other                                        $_________________

Total     $______________________________________


Please answer the following questions on an attached piece of paper:

  1. Please explain why your organization is important in meeting the social service needs of the Shippensburg Area.
  2. Please attach a brief summary of your organization’s accomplishments this past year.
  3. Please provide us with your goals and plans for the coming year.
  4. Finally, if your funding request is not met, please tell us how you will continue to provide services within the Shippensburg Area.




United Way of the Shippensburg Area Counterterrorism Compliance


In compliance with the spirit and intent of the USA PATRIOT ACT and other counterterrorism laws, 
The United Way of the Shippensburg Area requests that each funded agency (*Organization*) 
that it is in compliance with The United Way of the Shippensburg Area (*UWSA*) and the United Way
Worldwide (*UWW*) compliance program.            
Phone Number____________________________________________________________________
Check the Appropriate Box to Indicate Your Compliance with Each of the Following:
Comply  Do Not Comply                  
    This Organization is not on any federal Terrorism "watch lists," Including the list in
    Executive Order 13224, the master list of specially designated nationals and blocked
    persons maintained by the Treasury Department, and the list of Foreign Terrorist 
    Organizations maintained by the State Department.      
    This Organization does not, will not and has not knowlingly provided financial, technical, 
    in-kind, or other material support or resources to any individual or entity that is a terrorist
    or terrorist organization, or that supports or funds terrorism.    
    This Organization does not, will not and has not knowlingly provided or collected funds
    or provided material support or resources with the intention that such funds or material
    support or resources be used to carry out acts of terrorism.    
    This Organization does not, will not and has not knowlingly provided financial or material
    support or resources to any entity that has knowlingly concealed the source of funds
    used to carry out terrorism or to support Foreign Terrorist Organizations.  
    This Organization does not re-grant to organizations, individuals, programs, and/or 
    projects outside the United States of America without compliance to IRS guidelines.
    This Organization takes reasonable, affirmative steps to ensure that any funds or 
    resources distributed or processed do not fund terrorism of terrorist organizations.
    This Organization takes reasonable steps to certify against fraud with respect to the 
    provision of financial, technical, in-kind or other material support or resources to terrorist
In the form, "material support and resources" means currency or monetary instruments or financial 
securities, financial services, lodging, training, expert advice, or assistance, safehouses, false
documentation or identification, communications equipment, facilities, weapons, lethal substances,
explosives, personnel, transportation, and other physical assets, except medicine or religious materials.
I certify on behalf of the Organization listed above that the foregoing is true:

Print Name:_______________________________________ 






Campaign Year Date:_______________________________